Central Vein Sign, PRLs, and the Future of MS Imaging

Multiple sclerosis (MS) is a highly heterogeneous disease. Patients with similar presentations can follow very different courses, and that variability has pushed the field toward precision medicine. The goal of precision medicine is to use each patient’s clinical, biological, and imaging profile to guide diagnosis and treatment, rather than applying the same strategy to everyone. Clinicians now have more therapies and more sophisticated tools than ever, but how to turn that information into individualized care is still being worked out.

NeurologyLive® explores that challenge in its Roundtable series Precision Medicine in Multiple Sclerosis: Advances & Unanswered Questions, produced in collaboration with Cleveland Clinic Neurological Institute. The discussion brings together Robert Bermel, MD, director of Cleveland Clinic’s Mellen Center for Multiple Sclerosis Treatment and Research; Marisa McGinley, DO, staff neurologist at the Mellen Center; and Rebecca Cebull, CNP, certified nurse practitioner at the Mellen Center. Over the course of the series, the panel looks at the tools and evidence shaping individualized MS care and the questions that still stand in the way.

In episode 3, the conversation shifts to advanced MRI and its role beyond conventional lesion counts. Bermel makes the case for bringing the central vein sign, now part of the MS diagnostic criteria, into routine practice, arguing that an accurate diagnosis is the foundation of any personalized treatment strategy. Because susceptibility-weighted imaging is widely available, he encourages neurologists to work with local radiologists to report it. Cebull adds that the technique has become routine in her practice, where it helps reassure long-term patients about their diagnosis and clarify whether new lesions on high-efficacy therapy reflect true breakthrough disease.

McGinley notes that Cleveland Clinic has added sequences for both the central vein sign and paramagnetic rim lesions (PRLs) to many of its scanners, though PRLs are harder to acquire and read. She points to early tolebrutinib data suggesting PRLs may help gauge treatment response in progressive disease, while cautioning that atrophy measures still lack standardization across institutions. Bermel closes by urging neurologists to start recognizing and documenting PRLs now, even before they become actionable.